1013671429 NPI number — FOOTHILLS ORTHOPEDIC & SPORT THERAPY, PC

Table of content: (NPI 1013671429)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013671429 NPI number — FOOTHILLS ORTHOPEDIC & SPORT THERAPY, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOTHILLS ORTHOPEDIC & SPORT THERAPY, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013671429
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2964 GINNALA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOVELAND
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
80538-2701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
970-667-7755
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3938 JFK PKWY UNIT 11E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT COLLINS
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80525-3087
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
970-207-1500
Provider Business Practice Location Address Fax Number:
970-207-0075
Provider Enumeration Date:
10/22/2021

Additional Information

Authorized Official

Authorized Official Last Name:
PEDERSEN
Authorized Official First Name:
DUANE
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
PRACTICE MANAGER
Authorized Official Telephone Number:
970-667-7755

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02103354 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".




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